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PubMed2005

Pain reduction by fibrin sealant in older children and adult tonsillectomy.

OBJECTIVES: Because tonsillectomy is a painful procedure in adults, this study was performed to see whether the addition of fibrin sealant (Tisseel) to the tonsillar fossa at the completion of tonsillectomy would reduce pain in adults and allow them to return to work sooner. STUDY DESIGN: Forty adult patients over the age of 12 were entered into a prospective randomized study to see whether the addition of fibrin sealant (Tisseel) to the tonsillar fossa at the completion of tonsillectomy for recurrent tonsillitis would reduce the time the patient needed to take narcotic analgesics after surgery. METHODS: Fifteen adults had a traditional complete tonsillectomy by means of a needle point Bovie and served as a control group. Twenty-five (adults had the same procedure with the addition of Tisseel to see how long they required narcotic analgesics postoperatively and when they were able to resume normal activities. RESULTS: The control group took narcotics for an average of 10.3 days, whereas the addition of Tisseel reduced the time to 8.16 days (P = .0058). This significant reduction of time allowed adults to return to work and other activities sooner. CONCLUSION: Because the time required to return to work is often of paramount interest to patients having surgery, Tisseel should be considered a safe addition to older children and adult tonsillectomy in patients who are not allergic to bovine products because it will allow an earlier return to normal activities.

Adolescent↗
PubMed2006

Medical care of employees long-term sick listed due to mental health problems: a cohort study to describe and compare the care of the occupational physician and the general practitioner.

OBJECTIVES: To describe medical management by the general practitioner (GP) and occupational physician (OP) of workers sick listed due to mental health problems, and to determine agreement in diagnosis, main cause of sickness absence and obstacles in return to work. METHODS: A cohort of 555 employees being sick listed for 12 to 20 weeks due to mental health problems was recruited and followed for 1 year. These employees were interviewed about their mental health and contacts with GP, OP, other specialists and employer. In addition, the GP and/or the OP of 72 employees were interviewed about the medical diagnosis and management. RESULTS: Most employees sick listed for 12-20 weeks visited their GP and OP. According to the employees most interventions applied by the GP were medical interventions, such as referral of employees and prescription of medical drugs. Working conditions were seldom discussed by the GP and work-related interventions were never applied. Most interventions applied by the OP were work-related interventions and/or contact with the employer. The OP more often talked about working conditions and conflicts. According to the employees, the communication between GP and OP only took place in 8% of the cases. Agreement in the diagnosis, main cause of sickness absence, and obstacles in return to work reported by the GPs and OPs of the same employee was poor. In addition, similarity in reported diagnosis by GP and/or OP and the employees' scores on valid questionnaires on (mental) health was limited. CONCLUSIONS: The lack of communication and agreement by Dutch GPs and OPs in medical diagnosis and management of employees long-term sick listed due to mental health problems are indicators of sub-optimal medical treatment and return-to-work strategies.

Adult↗
PubMed1994

Effect of discharge recommendations on outcome.

STUDY DESIGN: The incidence of two common discharge recommendations, return to work unrestricted (RTWU) and restricted (RTWR) suggested that most restrictions were applied on the basis of patients' subjective reports of pain or therapists' unfounded fears that return to full duty would result in physical harm. OBJECTIVES: This prospective study compares the therapist's return to work recommendation to the patient's actual work status and analyzes the effect of that recommendation on outcome. METHODS: There were 1438 consecutive patients reviewed by structured telephone interviews during the two halves of the study: the control group when pain was accepted as a reason for restriction and the study group when it was not. SUMMARY OF BACKGROUND DATA: In the control group, 44% of the patients were recommended to RTWU; for the study group, 81% received this recommendation. Compliance was 84% for the control subjects and 78% for the study group. RESULTS: The absolute number of patients who returned to unrestricted work doubled in the study group. CONCLUSIONS: The probability of a successful return to normal duty increased with a recommendation of RTWU (P = 0.0001), whereas the probability of failure increased when restrictions were imposed (P = 0.0001).

Adult↗
PubMed1995

The centralization phenomenon. Its usefulness as a predictor or outcome in conservative treatment of chronic law back pain (a pilot study).

STUDY DESIGN: Two-hundred-forty-three patients with chronic low back pain were studied in a prospective comparative survey to determine whether the "centralization phenomenon" was associated with outcome after an interdisciplinary work-hardening program. OBJECTIVE: The hypothesis was that patients who demonstrated centralization during initial mechanical assessment would have better outcomes than noncentralizers. SUMMARY OF BACKGROUND DATA: Overall, subjects had decreased pain intensity ratings (mean 20%), increased lifting ability (6-8 kg), and a 59.2% return-to-work rate at a mean of 9.7 months follow-up. METHODS: Patients were classified as either centralizers or noncentralizers, based on results of their initial assessment. Changes in pain ratings, one-time maximal weights lifted, Oswestry scores, and return-to-work status were compared between groups. RESULTS: The centralizers reported significant decreases in their maximum pain ratings (centralizers, 16%; noncentralizers, 6%) and had a higher return-to-work rate (centralizers, 68%; noncentralizers, 52%) than the noncentralizers. CONCLUSION: Centralization can help identify sub-groups within the population with chronic low back pain and could be a useful goal setting and case management tool in the rehabilitation of low back pain.

Adult↗
PubMed1994

Laparoscopic repair of inguinal hernia.

OBJECTIVE: To present the outcome of 123 groin hernias treated laparoscopically between July 1991 and October 1993, and to discuss the advantages of preperitoneal hernia repair with mesh. DESIGN: Data for each patient were collected prospectively on a predetermined standard form. Every patient was assessed by an independent, non-treating surgeon. PATIENTS AND SETTING: Ninety-seven patients underwent laparoscopic hernia repair by two surgeons between July 1991 and October 1993. The patients were treated in several private hospitals and one public hospital in Sydney, NSW. MAIN OUTCOME MEASURES: Each patient was assessed for integrity of the hernia repair, the number of days before return to work, analgesic requirement after surgery, and complications. RESULTS: There were five hernia recurrences, and repairs in three other patients were considered doubtful by the non-treating surgeon assessor; these repairs were later judged to be sound. There were no infections and no serious complications. There was one scrotal haematoma, one incisional hernia through a trocar site, one hydrocoele and one trocar injury to a large branch of the inferior epigastric artery. Sixty-two per cent of patients required no analgesic injections. Patients covered by workers' compensation returned to work an average of 24 days after their operations and employed patients not covered returned to work an average of 12 days after their operations. Twenty-one patients had been treated previously by open inguinal herniorrhaphy and all enthusiastically endorsed the laparoscopic repair because of reduced pain and earlier return to physical activity. One patient was found to have omental adhesions to the site of the hernia repair at a subsequent laparoscopy. CONCLUSIONS: Laparoscopic inguinal herniorrhaphy has the advantages of reduced pain and rapid return to normal activity when compared with open techniques. The mesh prosthesis placed in the preperitoneal space behind the weakened inguinal region appears to confer strength and eliminates the disadvantage of tension observed with sutured repairs.

Adult↗
PubMed2003

One-level one-sided lumbar disc surgery with and without microscopic assistance: 1-year outcome in 114 consecutive patients.

OBJECT: The aim of this study was to compare the outcomes following macrodiscectomy and microsurgery for one-level one-sided lumbar disc excision. METHODS: The authors prospectively studied 114 consecutive patients who underwent microdiscectomy (Group A, 63 patients [36 men, 27 women]) and macrodiscectomy (Group B, 51 patients [29 men, 22 women]) for one-level unilateral first-time lumbar disc herniation. Microdiscectomy was considered to involve a small incision with removal or opening of the ligamentum flavum, no or minimal bone excision, and use of the operating microscope to remove the disc material. Laminectomy combined with macrodiscectomy was defined as any operation requiring a large opening in or complete removal of the unilateral lamina. Diagnosis was confirmed by magnetic resonance imaging. A 1-year follow-up investigation was also conducted. Relief of radicular pain, improvement in muscle power, and changes in sensory and/or reflex abnormality were documented. Assessment of outcome was performed using the modified Stauffer-Coventry criteria. Good or excellent results were demonstrated in 90% of Group A and 89% of Group B patients (p > 0.05). One patient in each group underwent reoperation. There was infection over the fascia in two Group A patients. Mean operative time (+/- standard deviation) was 54 +/- 5.65 minutes in Group A and 25 +/- 7.07 minutes in Group B (p < 0.01). Median length of the incision was 4 and 6 cm in Group A and Group B, respectively (p < 0.05). The length of postoperative inpatient stay was 1 day in both groups (p > 0.05). Patients in the microsurgery-treated group returned to work in less time: 85% of Group A and 58% of Group B patients returned to their work within 4 weeks (p < 0.001). Some patients in each group (15% in Group A and 45% in Group B) needed narcotic analgesic medication at least twice between the 1st month and 1st year after the surgery (p < 0.001). CONCLUSIONS: Microdiscectomy allows the surgeon good visualization and is less traumatic to the involved tissues. Interestingly, the results of this study indicated that microsurgery does not reduce hospitalization time, nor does it improve the overall surgery-related outcome. The main differences between the two procedures were length of the incision and operative time. The author found that lumbar microdiscectomy allows patients earlier return to work and/or normal life with less reliance on postoperative narcotic analgesic agents.

Activities of Daily Living↗
PubMedDate not supplied

Posttraumatic stress disorder in electric burn patients.

It was hypothesized that burn injuries electric in origin may have a poor prognosis for rehabilitation and return to work. Ten electrically injured burn patients were compared to seven patients whose burns were nonelectric, after all 17 had shown clinically significant emotional problems during rehabilitation. Results of psychological tests from both groups were also compared to results in three other groups: psychiatric, chronic pain, and blepharospasm patients. Results indicated that patients with electric burns had the most severe psychopathologic symptoms and the least likelihood of returning to work. Only the factor of educational background was predictive of degree of psychological distress, prognosis for returning to work, and response to psychological intervention. Results are discussed within a one-trial aversive conditioning paradigm potentially unique to electric injuries.

Adult↗
PubMed1999

The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy.

In a prospective controlled trial on 46 patients undergoing lumbar discectomy, three classes of variables (medical data including MRI-identified morphological abnormalities, general psychological factors and psychosocial aspects of work) were analyzed with regard to their predictive value for the outcome of lumbar disc surgery at 2 year follow-up. Multiple regression analyses were used to identify the best predictor variables of four different outcome measures (i.e. pain relief, reduction of disability in daily activities, return to work and surgical outcome). MRI-identified nerve root compromise and social support from the spouse were independent predictors of pain relief 2 years after surgery (R2 = 0.40, P < 0.01). Return to work 2 years after surgery was best predicted by depression and occupational mental stress (R2 = 0.36, P < 0.001). MRI-identified extent of herniation and depression were significant predictors of a good surgical outcome after lumbar discectomy (R2 = 0.61, P < 0.001). This study has demonstrated that the outcome of discectomy is critically dependent on which outcome variables are selected and that different sorts of predictor variables have a distinct influence on the various outcome variables. Obvious morphological alterations (i.e. disc extrusions, nerve root compromise) proved to be significant predictors of postoperative pain relief and improvement of disability in daily activities justifying a surgical treatment approach in these cases. The most important finding of this study was that return to work was not influenced by any clinical findings or MR-identified morphological alterations, but solely by psychological factors (i.e. depression) and psychological aspects of work (i.e. occupational mental stress).

Activities of Daily Living↗
PubMed1988

Flashbacks after traumatic hand injuries: prognostic indicators.

Flashbacks of a traumatic hand injury may compromise a patient's rehabilitation process. This study examined the nature and significance of these flashbacks in a work-injured population. We also evaluated the ability of these patients to return to work at the site of the original injury. Sixty-one patients with work-related, traumatic hand injuries received psychological evaluation and treatment. All patients experienced flashbacks. The following three types of flashbacks were identified: (1) a replaying of the events occurring just before the accident and continuing until the injury (replay flashbacks), (2) an image of the injured hand just after the trauma occurred (appraisal flashbacks), and (3) images in which an injury that was more severe than the one that actually occurred were perceived (projected flashbacks). Regardless of the result of injury, patients with replay flashbacks were the most likely to return to their former employment (95.2%) after only 4.8 1-hour sessions of psychotherapy for control of symptoms. Patients with a combination of appraisal and projected flashbacks were the least likely to return to work (10.3%), despite the fact they received an average of 13.1 1-hour sessions of psychotherapy.

Accidents, Occupational↗
PubMed2005

Quality of life after stroke: well-being, life satisfaction, and subjective aspects of work.

Stroke incidence in those of working age has been reported to be increasing significantly, implying strong incentives for research concerning working ability after stroke. This study focused on differences in subjective aspects of work and dimensions of quality of life after having experienced stroke. Sixty-five persons answered a postal questionnaire. The median age at the time of the stroke was 54 years, (Q3 -Q1 = 8 years). "Financial aspects" and "intrinsic aspects" of work were rated as the most important by 37% and 36% of the respondents, respectively. Fewer respondents ranked "social aspects" as most important. In total, 23 persons had returned to work, but no difference in the ratings of the most important aspects of work between those who had returned to work and those who had not was found. Persons who rated "intrinsic aspects" of work as the most important were more satisfied with the subjective dimensions of quality of life "vocational situation" (p = 0.020) and "work" (p = 0.015) than the others. In conclusion, subjective aspects of work need to be explored and discussed thoroughly in rehabilitation of younger stroke patients.

Employment↗
PubMed2003

An occupational therapy work skills assessment for individuals with head injury.

BACKGROUND: Comprehensive and accurate evaluation is a critical step in the return-to-work process for individuals with head injury. Research findings have been reported on the barriers for a successful return to work. Assessment frameworks have been published, but they do not include a protocol that contains each component for the assessment. METHOD: This paper describes an occupational therapy assessment protocol developed and used in the evaluation of the work skills of individuals with head injury. This protocol focuses on assessment of physical, cognitive and behavioural abilities in relation to the demands of the workplace and measures these within the framework of productivity, interpersonal skills and safety. PRACTICE IMPLICATIONS: The functional approach inherent in this protocol provides information to complement the findings of other interdisciplinary team members. This paper also explores the strengths and limitations of this protocol.

Brain Injuries↗
PubMed1994

Employment following traumatic head injuries.

OBJECTIVE: Determine rates of, and factors predictive of, return to work in patients with civilian traumatic head injuries. DESIGN: Inception cohort study with 1- to 2-year follow-up. SETTING: Hospitalized patients in a level I trauma center. PATIENTS: Three hundred sixty-six hospitalized head-injured subjects who were workers before injury and 95 comparison subjects participated in prospective, longitudinal investigations of employment following head injury. Head-injured and comparison subjects were similar on basic demographics and preinjury employment status. The comparison subjects consisted of patients who sustained traumatic injury to the body but not to the head. MAIN OUTCOME MEASURE: Time taken to return to work following head injury. RESULTS: Survival methodology was used for analysis. Whether patients returned to work and when related to both the characteristics of the injured patients (eg, education, preinjury work history), the severity of head injury and associated neuropsychologic problems, and severity of other system injuries. More precise predictions were possible using the multivariate model. CONCLUSIONS: The present study provides a means of assessing employment potential predictively. This can be useful for clinical and research purposes. The results should be used cautiously and should stimulate discussions of appropriate use of services and resources to meet individual patients' needs.

Adult↗
PubMed1996

The use of implantable direct current stimulation in multilevel spinal fusion without instrumentation. A prospective clinical and radiographic evaluation with long-term follow-up.

STUDY DESIGN: A prospective study with long-term follow-up of 143 patients who underwent spinal fusion with direct current stimulation and no instrumentation. OBJECTIVES: To assess the effects of direct current stimulation on fusion success, clinical outcome, and return to work in multilevel lumbar spinal fusion procedures. SUMMARY OF BACKGROUND DATA: Efforts to ensure higher fusion success rates in multilevel procedures have resulted in the use of surgical adjuncts, such as spinal instrumentation systems and electrical stimulation. METHODS: Patients were assessed 3, 6, 12, 18, and 24 or more months after surgery (long-term follow-up). Fusion was determined by anteroposterior and lateral radiographs and lateral bending films and was considered successful if there was evidence of bony fusion and the absence of motion between the operated vertebrae. Surgical technique included either a posterior facet or posterolateral fusion. RESULTS: There were no significant differences (P > 0.05) in fusion success between 12-month results and the long-term results. The median length of the long-term follow-up period was 5.0 years (range, 2-9 years) Nineteen patients were lost to follow-up; five were unwilling to return for assessment, and one patient died. Fusion success among the remaining 118 patients was 91.5%. Two-level procedures (90) had a fusion rate of 93%. Three-level procedures (22) had a fusion rate of 91%. Eighty-five patients (72%) had no pain; 27 patients (23%) had mild pain occasionally, and six patients (5%) had some degree of moderate pain. One hundred patients (85%) returned to work; 12 (10%) retired; five (4%) were not working before the surgery, and one patient (1%) was unable to return to work. There were no worker's compensation patients, and there were no major surgical complications in this series. CONCLUSIONS: Multilevel fusion in this series with long-term follow-up evaluation of direct current stimulated patients without instrumentation showed clinical and radiographic success higher than in recent studies without instrumentation and comparable with recent studies using instrumentation.

Adult↗
PubMed1996

Outcome measures of a chronic pain program: a prospective statistical study.

OBJECTIVE: To provide outcome data measuring objective and subjective variables of an individualized, multidisciplinary, comprehensive pain management program. DESIGN: The study is a prospective evaluation of 50 consecutive patients who completed the pain management program. Objective measures were medication use and return to work. Subjective measures included self-reports of pain levels and completion of a Personal Concerns and Goals Assessment (PCGA) examining issues of lifestyle and emotional well-being. These measures were compared at program onset and completion by using appropriate statistical analyses. RESULTS: Objective measures: Medication use by the study subjects decreased overall by 72% within all drug categories. Opioid use was eliminated. Regarding return to work, the study subjects increased their work hours by twofold overall. Of patients working fewer than 30 h per week at program onset, representing 62% of the study population, a fivefold return to work was observed. Subjective measures: Overall pain levels improved by 33%, with an 18 to 47% improvement in all descriptors (average pain levels on good or bad days, average number of good or bad days). Of the PCGA factors, patients improved 24 to 46% in all categories concerning lifestyle and emotional well-being. Correlative analysis of the data produced prognostic information as well as insights into chronic pain development. CONCLUSIONS: This study of objective and subjective outcome measures demonstrates that a comprehensive program employing specific principles and methods produces an effective approach for the management of chronic pain. Patients disabled by chronic pain regain a quality of life that allows them to resume a functioning, productive role.

Adolescent↗
PubMed2001

Two-year health and employment outcomes among injured workers enrolled in the Washington State Managed Care Pilot Project.

BACKGROUND: Increasing numbers of injured workers are being treated through managed care delivery systems, yet little is known about the long-term effects of care provided through these systems. We analyzed health outcomes, return to work, and employment status at 2 years post-injury among a cohort of workers who were previously enrolled in the Washington State Managed Care Pilot Project. METHODS: Data on functional status, satisfaction with quality of life, return to work and employment status were gathered via telephone interviews and mailed questionnaires from a subset of 374 injured workers who had a time loss claim that involved 4 or more days of lost work time. Of these 374 subjects, 106 were treated through managed care and 268 through fee-for-service (FFS) arrangements. Health outcomes were assessed through the SF-36, the Health Assessment Questionnaire (HAQ), and the Satisfaction with Quality of Life (QOL) instruments. Standard univariate and multivariate statistical methods were used to compare the two groups with respect to the health and employment outcomes. RESULTS: There were no statistically significant differences between the two groups in functional status, satisfaction with quality of life or employment outcomes, except in regard to perceived recovery. FFS patients were more likely to indicate their recovery at 2 years post injury was going well (62 vs. 45%, P = .01). Almost 90% of the injured workers returned to work at some point following their injury and 72% reported working during the 4 weeks prior to their 2-year follow-up interview. CONCLUSIONS: Injured workers treated through managed care, based upon an occupational-medicine model, appear to experience similar long-term health and employment outcomes as workers treated through traditional FFS.

Accidents, Occupational↗
PubMed1993

Endoscopic carpal tunnel release: a comparison of two techniques with open release.

Proponents of endoscopic carpal tunnel release claim less pain and scar tenderness, quicker recovery of strength, and earlier return to work and daily activities over open methods to release the transverse carpal ligament. This single-center prospective study is the first to compare three different treatment methods: standard open release, a single-portal endoscopic technique (Agee), and a two-portal endoscopic technique (Chow). Two hundred eleven releases in 163 patients were evaluated by clinical outcomes questionnaire and objective testing over a 6-month follow-up period. There was no difference in resolution of paresthesias or nocturnal pain between treatment methods. Patients treated with open release reported more thumb weakness and pain with activities of daily living after surgery. Endoscopically treated patients achieved faster recovery of grip and pinch strength and wrist range of motion. Patients treated endoscopically had less mid-palm tenderness than did patients treated via the open technique, and Agee patients had less distal palmar tenderness than did patients treated via other methods. Overall, and in the workers' compensation group, patients treated endoscopically returned to work sooner. In the non-workers' compensation group, Agree patients returned to work sooner than did patients treated via the other two methods.

Activities of Daily Living↗
PubMed1992

Pedicle screw instrumentation for thoracolumbar burst fractures and fracture-dislocations.

Thirty-eight patients with unstable thoracolumbar and lumbar (T12-L5) spine fractures were treated with Cotrel-Dubousset pedicle screw instrumentation. They were followed for an average of 22.73 months (range 12-39). Measurements of canal compromise, wedge index, and kyphosis correction at follow-up examination were made. Thirty-three (86%) patients responded to a questionnaire concerning overall satisfaction, use of pain medication and return to work. There was an overall correction of kyphosis at follow-up of only one degree after a loss of six degrees from operative correction. There were nine cases of bent or broken screws that occurred at the thoracolumbar junction. Only one patient with instrumentation required continued pain medication and most had returned to work. Thirty-two of thirty-three patients were satisfied with the overall surgical result and twenty-eight of thirty-three patients had returned to work.

Adult↗
PubMed1998

Transabdominal or totally extraperitoneal laparoscopic hernia repair?

Laparoscopic repair of inguinal hernias follows some principles that have already proven its efficiency, as a posterior approach and the prosthetic repair that allows a "tension-free" repair with consequent early return to work and low recurrence rate. To determine the most appropriate laparoscopic repair, we compared the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP) approach. Patients undergoing TAPP and TEP were compared regarding technical feasibility and difficulties, time until return to work and follow-up, including intraoperative and postoperative complications. Seventy-eight patients (108 hernias) were submitted to TAPP and 67 (100 hernias) were repaired through TEP. All data were analyzed by Yates-corrected chi-square test to qualitative analysis of each group and p < or = 0.05 was considered significant. Both procedures were indicated mainly for bilateral and/or recurrent hernias (68%). The operative time was shorter in TAPP (not statistically significant). Surgeons complained of more technical difficulties while performing the TEP approach (70% complaints of difficulty in TEP--four conversions to TAPP). There was no difference in hospital stay (mean of 30 h) and return to work (TAPP 7 days and TEP 5.5 days). Regarding the complication rate (TAPP = 20.5% and TEP = 13.5%; not significant), none were related to the pneumoperitoneum technique or its systemic effects. In the TAPP approach, two trocar site hernias occurred, and in the TEP approach, one severe cellulitis occurred, which was managed without surgical intervention. The mean follow-up period for each procedure was not the same, so the recurrence rates are not comparable statistically (rate of 1.85% in TAPP and 0 in TEP). Both techniques are safe and have the same advantages, but TAPP is easier: a better view of the anatomy is achieved, shortening the learning curve. We suggest that TAPP can be an adequate laparoscopic approach to groin hernias. A longer follow-up period and more cases are needed to determine recurrence rates.

Adult↗